Managing radiation-associated oral toxicities remains challenging, but evidence-based clinical practice guidelines are now available for oral mucositis, and the field is on the cusp of genomics-based patient risk stratification, says an expert in the field.
Radiation therapy of the head and neck frequently causes acute and late oral toxicities, including mucositis, trismus due to fibrosis, impaired or lost saliva production (xerostomia), and xerostomia-related radiation dental caries (cavities).1-6 Oral mucositis is a particularly common and painful side effect of radiotherapy and chemoradiation for head and neck cancer; it can lead to malnutrition, infection, and disruptions in cancer treatment.1-6 Oral mucositis is also increasingly common among patients with breast cancer, who are treated with conventional chemotherapy and newer targeted therapies.7
“Patients receiving radiation therapy for head and neck cancer almost always develop radiation-induced oral mucositis,” notes Rajesh V. Lalla, DDS, PhD, associate professor of Oral Medicine at the University of Connecticut Health Center in Farmington, Connecticut, a leading researcher on the treatment of mucositis. “These lesions are very painful and can have significant negative impact on patients’ ability to maintain a normal diet. Patients often need to be fed via a stomach tube and receive strong opioid pain medications.”
In some cases, oral symptoms are so severe that radiotherapy must be interrupted or discontinued, which can affect the success of a cancer treatment plan, Lalla tells Oncology Nurse Advisor.
“Any patient for whom the radiation field includes oral mucosa is at risk,” agrees another authority in the field, Stephen Sonis, DMD, DMSc, professor of Oral Medicine at Harvard School of Dental Medicine and senior surgeon at Brigham and Women’s Hospital and the Dana-Farber Cancer Institute, in Boston, Massachusetts. “Cumulative doses of radiation greater than 30 Gy almost always produce ulceration [of the oral mucosa]. Thus, patients being treated with standard chemoradiation regimens for cancers of the mouth and oropharynx are at high risk for oral mucositis, and 70% or more develop severe oral mucositis.”
Patients treated with similar regimens for hypopharyngeal or laryngeal cancers are at slightly lower risk of oral mucositis—approximately 60%, Sonis says—but face higher risk of developing hypopharyngeal lesions.
Unlike xerostomia, which can be permanent in patients who undergo radiotherapy or chemoradiation of the head and neck, oral mucositis usually resolves once radiotherapy ends.
“While the time to spontaneous resolution of oral mucositis may vary among [patients] from about 2 to 6 weeks following the last day of radiation, it is very unusual for chronic lesions to persist,” Sonis explains.
Despite the high incidence of oral mucositis, impact on patients’ quality of life and treatment plan implementation, and economic costs, there are few treatment options. “Palifermin (Kepivance) is approved for use in preventing severe oral mucositis in patients receiving conditioning regimens prior to stem cell transplant for hematologic malignancies,” notes Sonis.
A number of palliative agents, approved as devices, are available to help mitigate mucositis pain including GelClair, Episil, and MuGard.8
Management of oral mucositis includes general supportive care, pain management, and infection prevention and treatment. Lalla was lead author of evidence-based clinical practice guidelines for oral mucositis that were promulgated by the Multinational Association of Supportive Care in Cancer (MASCC), in affiliation with the International Society of Oral Oncology (ISOO).3
A summary of the MASCC/ISOO mucositis guidelines are available online.